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QUALITY COUNTS
Reducing Hospital Readmissions A closer look at the Medicare Hospital Readmissions Reduction Program. This column is designed to provide a nursing perspective on new hospital quality measurements. Future articles will cover the various quality indicators hospitals face and the role of the nurse in meeting mandated benchmarks. Reader responses to this column are welcome and will help to make it more useful to nurses in meeting the challenges posed by health care reform and changing Medicare reimbursement programs.
M
uch of the public discussion about the Affordable Care Act (ACA) has focused on the effort to provide health care coverage for uninsured Americans, but the legislation has two other main goals: to improve the quality of the health care delivery system and to reduce health care costs. While there’s controversy about the best ways to realize these overarching priorities of health care reform, few would dispute the pressing need to achieve both ends. As noted in my first column (see “The New World of Health Care Quality and Measurement,” July 2014), the ACA authorized the Centers for Medicare and Medicaid Services (CMS) to establish three payfor-performance programs to improve the quality of care in acute care hospitals while controlling costs: the Hospital Value-Based Purchasing (HVBP) program, the Hospital-Acquired Conditions (HAC) reduction program, and the Hospital Readmissions Reduction Program (HRRP). This article will focus on the HRRP. Readmission of recently discharged patients is a costly problem that all hospitals face, regardless of the size of the facility. A comprehensive 2009 study of Medicare claims data from 2003–2004 found that one in five of the nearly 12 million Medicare patients discharged during this period returned to the hospital within 30 days; one in three were readmitted within 90 days; and two-thirds of medical patients and half of surgical patients were rehospitalized or died within one year of discharge.1 The researchers estimated that unplanned hospital readmissions cost Medicare $17.4 billion in 2004. According to a 2007 Medicare Payment Advisory Commission report to the Congress, readmissions within 30 days of discharge accounted for about $15 billion of Medicare spending.2 This study also found that readmission rates varied by 62
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hospital and geographic location even after adjustment for severity level and type of disease, suggesting that costs are also unevenly distributed across hospitals and regions. According to an April 2014 statistical brief issued by the Agency for Healthcare Research and Quality (AHRQ), in 2011 3.3 million adult hospital patients were readmitted within 30 days of discharge, at a cost of $41.3 billion; 58% of those costs were attributed to Medicare patients.3 While hospital readmissions may be appropriate and necessary in some situations, many are potentially avoidable. Defining readmission. There are several ways to define hospital readmission. We’re concerned here with all-cause 30-day readmissions: that is, rehospitalization for any reason, regardless of the patient’s initial diagnosis, to any acute care facility within 30 days of discharge from the original facility. It should be noted that, by this definition, a small number of rehospitalizations that have nothing to do with the quality of in-hospital, discharge, or follow-up care are counted in the readmission rate (for example, hospitalization for injuries sustained by a cardiac patient who gets hit by a car a week after discharge). And there are exceptions to the general rule: patients who are discharged and transferred to another acute care facility; those who insist on leaving the hospital against medical advice; and others excluded because their readmissions are planned (for example, for additional testing or procedures). The CMS chose to evaluate all-cause readmissions for several reasons. From the patient’s perspective, readmission for any cause is an adverse event. And because many factors may contribute to a patient’s deteriorating health, it’s often difficult to determine the “primary” reason for the patient’s rehospitalization. Likewise, patients who have one or more chronic illnesses are at greater risk for readmission, and it’s ajnonline.com
By Jo Ann Brooks, PhD, RN, FAAN, FCCP
difficult to determine which readmissions should be deemed preventable. For example, consider a patient who’s initially hospitalized for heart failure and then develops a hospital-acquired infection that’s not detected until after discharge: it may not be clear whether the infection is the result of substandard hospital care. Also, our way of conceptualizing hospitalization and hospital discharge has changed: in the past, inpatient hospital care was considered a discrete event and discharge was defined as the completion of care. Today, however, it’s understood that the patient’s needs must be addressed across the continuum of care, from inpatient care to transition and discharge to appropriate follow-up care in the outpatient setting.
THE HRRP
In October 2012, the CMS started the HRRP as part of a multipronged approach to reducing hospital readmissions. The HRRP penalizes hospitals that have high rates of potentially preventable readmissions for specific medical conditions by lowering their Medicare payments, thus establishing a financial incentive to reduce readmissions.4 The HRRP’s financial target is to save $8.2 billion over a 10-year period.5 In year 1 of the HRRP, federal fiscal year (FY) 2013, all-cause 30-day readmission rates were measured for patients with three high-rate medical diagnoses: acute myocardial infarction, heart failure, and pneumonia. Three more diagnoses— chronic obstruc-
An underlying aspect of all interventions to reduce readmissions is the identification of patient information needs and improved communication with patients and families. Which patients are most often readmitted? ccording to the AHRQ brief referenced above, A among Medicare patients who later experienced allcause 30-day readmissions, the five most common principal diagnoses on initial hospitalization were congestive heart failure, septicemia (except in labor), pneumonia, chronic obstructive pulmonary disease, and cardiac dysrhythmias.3 Together, patients with these five conditions accounted for 463,500 allcause 30-day readmissions, at a cost of more than $6 billion. Reducing readmissions. A 2010 Congressional Research Service report enumerated many issues related to hospital readmissions and identified three parts of the care process that, if improved, could raise the overall quality of patient care and potentially reduce readmissions: the Medicare-covered hospital stay, the hospital discharge process, and postdischarge follow-up as patients transition from hospital to other care settings.4 The latter is especially important and has many components that depend on effective provider–patient communication, including patient and family caregiver education, adherence to prescribed medication regimens, and follow-up appointments with physicians. Today, hospitals that are trying to improve the quality of the care they provide and prevent rehospitalization target all three parts of the continuum of care. [email protected]
tive pulmonary disease, elective hip arthroplasty, and elective knee arthroplasty—were included in the penalty at the beginning of the current fiscal year, FY2015, which started October 1, 2014, and runs through September 30, 2015. Another diagnosis—coronary artery bypass graft—will be added in FY2017.6 Penalties. The penalties for underperforming hospitals are recalculated each year and take into account readmission data from three preceding years; for example, the penalty for FY2015 depends on hospitals’ performance from July 1, 2010, to June 30, 2013; in FY2016, data from July 1, 2011, to June 30, 2014, will be evaluated. In year 1 of the HRRP, the potential penalty for excessive all-cause 30-day readmissions was, at most, 1% of the base operating diagnosis-related group (DRG) payment for all Medicare inpatient discharges; the potential penalty increased to 2% of this amount in year 2 and reaches the maximum penalty, 3%, this year (year 3, FY2015). The penalty will remain at this level in the coming years unless the regulations change.6 Evaluating performance. To evaluate a given hospital’s performance, the CMS compares the hos pital’s actual readmission rate during the abovementioned three-year data collection period with its expected readmission rate, which is the national mean readmission rate for the same period with an AJN ▼ January 2015
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Vol. 115, No. 1
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QUALITY COUNTS
additional risk adjustment that takes into account the demographics of the hospital’s patient population and the patients’ severity of illness. The adjustment is intended to ensure that hospitals with patient populations whose severity of illness is worse than average aren’t unfairly penalized for having higher than average rates of readmission. However, there’s controversy about whether factors such as the hospital’s size and the socioeconomic status of the community it serves should be taken into account, so the way the risk adjustment is calculated is likely to change in the future.4 The difference between the actual and expected readmission rates is known as the excess readmission ratio, which is the critical measure of each hospital’s performance. If excess readmissions are greater than the national average, the hospital is penalized with reduced Medicare payments.
One stated goal of the latter program was to reduce all-cause 30-day readmissions by 20% in Medicare fee-for-service patients by the end of 2013.11 In fact, between January 2012 and December 2013 there were approximately 150,000 fewer readmissions among these patients, representing an 8% reduction in the total number of Medicare readmissions during this period. While the program, which is only one component of the national effort to reduce readmissions, did not meet its stated goal, the trend in readmissions seems to be moving in the right direction and should continue to do so as long as the steady focus on reduction is maintained. Nursing implications. Hansen and colleagues developed a “taxonomy of interventions,” which they categorized as predischarge, postdischarge, and bridging the transition.12 Nurses, as primary caregivers during the hospital stay and the providers who
If nurses are working in an inadequately staffed environment, the delivery of the care processes that can reduce rehospitalization may be hampered. Results. In the program’s first year, Medicare penalized 2,213 hospitals, approximately two-thirds of those evaluated, with fines totaling $280 million.7-9 The average penalty per hospital was 0.42% of the base operating DRG payment; 276 hospitals were fined the 1% maximum. In year 2 of the program, more hospitals (2,225) were penalized, but the total amount of money lost ($227 million) was less than in year 1.10 The average penalty per hospital in year 2 was 0.38% of the base operating DRG payment; only 18 hospitals were fined the 2% maximum. Other programs. It should be noted that the CMS has instituted programs other than the HRRP that aim to prevent or reduce readmissions, including the Hospital Compare Web site (www.medicare.gov/ hospitalcompare), which provides the public with a searchable online database on hospital readmission rates; the CMS Innovation Center, which supports new payment and service delivery models and administers funding grants known as the Health Care Innovation Awards (http://innovation.cms.gov/initiatives/ Health-Care-Innovation-Awards); and the Partnership for Patients (http://innovation.cms.gov/initiatives/ partnership-for-patients), which launched a variety of public–private partnerships with more than 3,700 hospitals to improve patient safety and care transitions. 64
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have the most contact with patients and family members, play a key role in these interventions and in reducing Medicare readmissions. Communication is perhaps the most important aspect of these interventions. Romagnoli and colleagues recently surveyed 119 home care nurses about their perceptions of older patients’ posthospitalization information needs and communication problems.13 The nurses identified communication needs including information about medication regimens, the severity of the patient’s condition, the hospital discharge management process, nonmedication care regimens, the use of durable medical equipment to promote home safety (for example, decreasing the risk of falling and improving access to the telephone), and the kind and degree of care needed and which providers are best suited to provide it. Many of these patients’ communication needs, such as for information about the severity of their illness, nonmedication care regimens, and postdischarge procedures, have not been previously identified in the literature. These authors suggest that improving information sharing among care providers, patients, and families during care transitions may improve patient outcomes, keep patients safer at home, and prevent unplanned readmissions. Thus, an underlying aspect of all interventions to reduce readmissions ajnonline.com
is the identification of patient information needs and improved communication with patients and families. Can nurses reduce hospital readmissions? Evidence has shown that if nurses are working in an inadequately staffed environment, the delivery of the care processes that can reduce rehospitalization may be hampered.14-17 Recently, McHugh and Ma examined the relationship between hospital nursing and 30-day hospital readmissions among Medicare patients with heart failure, acute myocardial infarction, and pneumonia.16 The researchers evaluated nurse staffing levels, nurse education, and nurses’ own assessment of their work environment, including such factors as the quality of nurse–physician relationships, nurse manager leadership, and nurses’ participation in organizational decision making. They analyzed patient discharge data from 412 hospitals and survey results from more than 20,000 nurses in California, New Jersey, and Pennsylvania, as well as data from the American Hospital Association Annual Survey. The study demonstrated that the probability of readmission increased with each patient added to the average nurse’s workload: by 9% among those with acute myocardial infarction, 7% among those with heart failure, and 6% among those with pneumonia. Compared with hospitals rated by nurses as having a poor working environment, hospitals with a good working environment had readmissions that were 10% lower among patients with pneumonia, 7% lower among patients with heart failure, and 6% lower among those with myocardial infarction. The authors found that nurses’ education level significantly affected readmissions for pneumonia but not for the other two diagnoses, noting that a “broader set of patient types should be considered to address the question of why having more nurses with BSNs affects readmissions for some patients and not others.” In summary, preventing or reducing readmissions requires efforts in several areas: not only evidencebased interventions but also a focus on system factors such as nurse staffing levels, work environment, and educational preparation. Regardless of their title or job description, all nurses play pivotal roles in reducing and preventing readmissions at a variety of points along the continuum of care, at the bedside, in discharge planning, and in postdischarge care management. Hospital readmissions are the result of many factors; therefore, many interventions across the continuum of care may be used to reduce them. In our efforts to reduce or prevent readmissions and improve patient care, we should focus on effective communication, coordination, and collaboration with patients, family members, and other care providers. Interdisciplinary teams are key in preventing readmissions, and nursing can lead the way. ▼ [email protected]
Jo Ann Brooks is system vice president, quality and safety, at Indiana University Health in Indianapolis. Contact author: [email protected]. The author has disclosed no potential conflicts of interest, financial or otherwise.
REFERENCES 1. Jencks SF, et al. Rehospitalizations among patients in the Medicare fee-for-service program. N Engl J Med 2009;360(14): 1418-28. 2. Medicare Payment Advisory Commission (MedPAC). Report to the Congress: promoting greater efficiency in Medicare. Washington, DC; 2007 Jun. http://medpac.gov/documents/reports/ Jun07_EntireReport.pdf. 3. Hines AL, et al. Conditions with the largest number of adult hospital readmissions by payer, 2011. Rockville, MD: Agency for Healthcare Research and Quality; 2014 Apr. HCUP statistical brief #172; http://www.hcup-us.ahrq.gov/reports/ statbriefs/sb172-Conditions-Readmissions-Payer.jsp. 4. Stone J, Hoffman GJ. Medicare hospital readmissions: issues, policy options and PPACA. Washington, DC: Congressional Research Service; 2010 Sep 21. CRS report for Congress R40972. 5. Foster RS. Estimated financial effects of the “Patient Protection and Affordable Care Act,” as amended Apr 22, 2010. http:// www.cms.gov/Research-Statistics-Data-and-Systems/Research/ ActuarialStudies/downloads/PPACA_2010-04-22.pdf. 6. Centers for Medicare and Medicaid Services. 42 CFR Parts 405, 412, 413, et al., Medicare program; hospital inpatient prospective payment systems for acute care hospitals and the long-term care hospital prospective payment system and fiscal year 2015 rates; etc.; final rule. Washington, DC: Federal Register 2014 49853-50536. 7. Centers for Medicare and Medicaid Services. FY2013 IPPS final rule: Hospital Readmissions Reduction Program supplemental data file. Baltimore, MD 2012. 8. Rau J. Medicare to penalize 2,217 hospitals for excess readmissions. KHN, Kaiser Health News 2012 Aug 13. http:// www.kaiserhealthnews.org/stories/2012/august/13/medicarehospitals-readmissions-penalties.aspx. 9. Rau J. Medicare revises readmissions penalties—again. KHN, Kaiser Health News 2013 May 14. http://www. kaiserhealthnews.org/stories/2013/march/14/revised- readmissions-statistics-hospitals-medicare.aspx. 10. Rau J. Armed with bigger fines, Medicare to punish 2,225 hospitals for excess readmissions. KHN, Kaiser Health News 2013 Aug 2. http://www.kaiserhealthnews.org/stories/2013/ august/02/readmission-penalties-medicare-hospitals-year-two. aspx. 11. U.S. Department of Health and Human Services. New HHS data shows major strides made in patient safety, leading to improved care and savings. Washington, DC; 2014 May 7 http://innovation.cms.gov/Files/reports/patient-safety-results.pdf. 12. Hansen LO, et al. Interventions to reduce 30-day rehospitalization: a systematic review. Ann Intern Med 2011;155(8):520-8. 13. Romagnoli KM, et al. Home-care nurses’ perceptions of unmet information needs and communication difficulties of older patients in the immediate post-hospital discharge period. BMJ Qual Saf 2013;22(4):324-32. 14. Kalisch BJ, et al. Missed nursing care: errors of omission. Nurs Outlook 2009;57(1):3-9. 15. McHugh MD, et al. Hospitals with higher nurse staffing had lower odds of readmissions penalties than hospitals with lower staffing. Health Aff (Millwood) 2013;32(10):1740-7. 16. McHugh MD, Ma C. Hospital nursing and 30-day readmissions among Medicare patients with heart failure, acute myocardial infarction, and pneumonia. Med Care 2013;51(1):52-9. 17. Weiss ME, et al. Quality and cost analysis of nurse staffing, discharge preparation, and postdischarge utilization. Health Serv Res 2011;46(5):1473-94.
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Reducing Hospital Readmissions A closer look at the Medicare Hospital Readmissions Reduction Program. This column is designed to provide a nursing perspective on new hospital quality measurements. Future articles will cover the various quality indicators hospitals face and the role of the nurse in meeting mandated benchmarks. Reader responses to this column are welcome and will help to make it more useful to nurses in meeting the challenges posed by health care reform and changing Medicare reimbursement programs.
M
uch of the public discussion about the Affordable Care Act (ACA) has focused on the effort to provide health care coverage for uninsured Americans, but the legislation has two other main goals: to improve the quality of the health care delivery system and to reduce health care costs. While there’s controversy about the best ways to realize these overarching priorities of health care reform, few would dispute the pressing need to achieve both ends. As noted in my first column (see “The New World of Health Care Quality and Measurement,” July 2014), the ACA authorized the Centers for Medicare and Medicaid Services (CMS) to establish three payfor-performance programs to improve the quality of care in acute care hospitals while controlling costs: the Hospital Value-Based Purchasing (HVBP) program, the Hospital-Acquired Conditions (HAC) reduction program, and the Hospital Readmissions Reduction Program (HRRP). This article will focus on the HRRP. Readmission of recently discharged patients is a costly problem that all hospitals face, regardless of the size of the facility. A comprehensive 2009 study of Medicare claims data from 2003–2004 found that one in five of the nearly 12 million Medicare patients discharged during this period returned to the hospital within 30 days; one in three were readmitted within 90 days; and two-thirds of medical patients and half of surgical patients were rehospitalized or died within one year of discharge.1 The researchers estimated that unplanned hospital readmissions cost Medicare $17.4 billion in 2004. According to a 2007 Medicare Payment Advisory Commission report to the Congress, readmissions within 30 days of discharge accounted for about $15 billion of Medicare spending.2 This study also found that readmission rates varied by 62
AJN ▼ January 2015
▼
Vol. 115, No. 1
hospital and geographic location even after adjustment for severity level and type of disease, suggesting that costs are also unevenly distributed across hospitals and regions. According to an April 2014 statistical brief issued by the Agency for Healthcare Research and Quality (AHRQ), in 2011 3.3 million adult hospital patients were readmitted within 30 days of discharge, at a cost of $41.3 billion; 58% of those costs were attributed to Medicare patients.3 While hospital readmissions may be appropriate and necessary in some situations, many are potentially avoidable. Defining readmission. There are several ways to define hospital readmission. We’re concerned here with all-cause 30-day readmissions: that is, rehospitalization for any reason, regardless of the patient’s initial diagnosis, to any acute care facility within 30 days of discharge from the original facility. It should be noted that, by this definition, a small number of rehospitalizations that have nothing to do with the quality of in-hospital, discharge, or follow-up care are counted in the readmission rate (for example, hospitalization for injuries sustained by a cardiac patient who gets hit by a car a week after discharge). And there are exceptions to the general rule: patients who are discharged and transferred to another acute care facility; those who insist on leaving the hospital against medical advice; and others excluded because their readmissions are planned (for example, for additional testing or procedures). The CMS chose to evaluate all-cause readmissions for several reasons. From the patient’s perspective, readmission for any cause is an adverse event. And because many factors may contribute to a patient’s deteriorating health, it’s often difficult to determine the “primary” reason for the patient’s rehospitalization. Likewise, patients who have one or more chronic illnesses are at greater risk for readmission, and it’s ajnonline.com
By Jo Ann Brooks, PhD, RN, FAAN, FCCP
difficult to determine which readmissions should be deemed preventable. For example, consider a patient who’s initially hospitalized for heart failure and then develops a hospital-acquired infection that’s not detected until after discharge: it may not be clear whether the infection is the result of substandard hospital care. Also, our way of conceptualizing hospitalization and hospital discharge has changed: in the past, inpatient hospital care was considered a discrete event and discharge was defined as the completion of care. Today, however, it’s understood that the patient’s needs must be addressed across the continuum of care, from inpatient care to transition and discharge to appropriate follow-up care in the outpatient setting.
THE HRRP
In October 2012, the CMS started the HRRP as part of a multipronged approach to reducing hospital readmissions. The HRRP penalizes hospitals that have high rates of potentially preventable readmissions for specific medical conditions by lowering their Medicare payments, thus establishing a financial incentive to reduce readmissions.4 The HRRP’s financial target is to save $8.2 billion over a 10-year period.5 In year 1 of the HRRP, federal fiscal year (FY) 2013, all-cause 30-day readmission rates were measured for patients with three high-rate medical diagnoses: acute myocardial infarction, heart failure, and pneumonia. Three more diagnoses— chronic obstruc-
An underlying aspect of all interventions to reduce readmissions is the identification of patient information needs and improved communication with patients and families. Which patients are most often readmitted? ccording to the AHRQ brief referenced above, A among Medicare patients who later experienced allcause 30-day readmissions, the five most common principal diagnoses on initial hospitalization were congestive heart failure, septicemia (except in labor), pneumonia, chronic obstructive pulmonary disease, and cardiac dysrhythmias.3 Together, patients with these five conditions accounted for 463,500 allcause 30-day readmissions, at a cost of more than $6 billion. Reducing readmissions. A 2010 Congressional Research Service report enumerated many issues related to hospital readmissions and identified three parts of the care process that, if improved, could raise the overall quality of patient care and potentially reduce readmissions: the Medicare-covered hospital stay, the hospital discharge process, and postdischarge follow-up as patients transition from hospital to other care settings.4 The latter is especially important and has many components that depend on effective provider–patient communication, including patient and family caregiver education, adherence to prescribed medication regimens, and follow-up appointments with physicians. Today, hospitals that are trying to improve the quality of the care they provide and prevent rehospitalization target all three parts of the continuum of care. [email protected]
tive pulmonary disease, elective hip arthroplasty, and elective knee arthroplasty—were included in the penalty at the beginning of the current fiscal year, FY2015, which started October 1, 2014, and runs through September 30, 2015. Another diagnosis—coronary artery bypass graft—will be added in FY2017.6 Penalties. The penalties for underperforming hospitals are recalculated each year and take into account readmission data from three preceding years; for example, the penalty for FY2015 depends on hospitals’ performance from July 1, 2010, to June 30, 2013; in FY2016, data from July 1, 2011, to June 30, 2014, will be evaluated. In year 1 of the HRRP, the potential penalty for excessive all-cause 30-day readmissions was, at most, 1% of the base operating diagnosis-related group (DRG) payment for all Medicare inpatient discharges; the potential penalty increased to 2% of this amount in year 2 and reaches the maximum penalty, 3%, this year (year 3, FY2015). The penalty will remain at this level in the coming years unless the regulations change.6 Evaluating performance. To evaluate a given hospital’s performance, the CMS compares the hos pital’s actual readmission rate during the abovementioned three-year data collection period with its expected readmission rate, which is the national mean readmission rate for the same period with an AJN ▼ January 2015
▼
Vol. 115, No. 1
63
$ $
$
QUALITY COUNTS
additional risk adjustment that takes into account the demographics of the hospital’s patient population and the patients’ severity of illness. The adjustment is intended to ensure that hospitals with patient populations whose severity of illness is worse than average aren’t unfairly penalized for having higher than average rates of readmission. However, there’s controversy about whether factors such as the hospital’s size and the socioeconomic status of the community it serves should be taken into account, so the way the risk adjustment is calculated is likely to change in the future.4 The difference between the actual and expected readmission rates is known as the excess readmission ratio, which is the critical measure of each hospital’s performance. If excess readmissions are greater than the national average, the hospital is penalized with reduced Medicare payments.
One stated goal of the latter program was to reduce all-cause 30-day readmissions by 20% in Medicare fee-for-service patients by the end of 2013.11 In fact, between January 2012 and December 2013 there were approximately 150,000 fewer readmissions among these patients, representing an 8% reduction in the total number of Medicare readmissions during this period. While the program, which is only one component of the national effort to reduce readmissions, did not meet its stated goal, the trend in readmissions seems to be moving in the right direction and should continue to do so as long as the steady focus on reduction is maintained. Nursing implications. Hansen and colleagues developed a “taxonomy of interventions,” which they categorized as predischarge, postdischarge, and bridging the transition.12 Nurses, as primary caregivers during the hospital stay and the providers who
If nurses are working in an inadequately staffed environment, the delivery of the care processes that can reduce rehospitalization may be hampered. Results. In the program’s first year, Medicare penalized 2,213 hospitals, approximately two-thirds of those evaluated, with fines totaling $280 million.7-9 The average penalty per hospital was 0.42% of the base operating DRG payment; 276 hospitals were fined the 1% maximum. In year 2 of the program, more hospitals (2,225) were penalized, but the total amount of money lost ($227 million) was less than in year 1.10 The average penalty per hospital in year 2 was 0.38% of the base operating DRG payment; only 18 hospitals were fined the 2% maximum. Other programs. It should be noted that the CMS has instituted programs other than the HRRP that aim to prevent or reduce readmissions, including the Hospital Compare Web site (www.medicare.gov/ hospitalcompare), which provides the public with a searchable online database on hospital readmission rates; the CMS Innovation Center, which supports new payment and service delivery models and administers funding grants known as the Health Care Innovation Awards (http://innovation.cms.gov/initiatives/ Health-Care-Innovation-Awards); and the Partnership for Patients (http://innovation.cms.gov/initiatives/ partnership-for-patients), which launched a variety of public–private partnerships with more than 3,700 hospitals to improve patient safety and care transitions. 64
AJN ▼ January 2015
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Vol. 115, No. 1
have the most contact with patients and family members, play a key role in these interventions and in reducing Medicare readmissions. Communication is perhaps the most important aspect of these interventions. Romagnoli and colleagues recently surveyed 119 home care nurses about their perceptions of older patients’ posthospitalization information needs and communication problems.13 The nurses identified communication needs including information about medication regimens, the severity of the patient’s condition, the hospital discharge management process, nonmedication care regimens, the use of durable medical equipment to promote home safety (for example, decreasing the risk of falling and improving access to the telephone), and the kind and degree of care needed and which providers are best suited to provide it. Many of these patients’ communication needs, such as for information about the severity of their illness, nonmedication care regimens, and postdischarge procedures, have not been previously identified in the literature. These authors suggest that improving information sharing among care providers, patients, and families during care transitions may improve patient outcomes, keep patients safer at home, and prevent unplanned readmissions. Thus, an underlying aspect of all interventions to reduce readmissions ajnonline.com
is the identification of patient information needs and improved communication with patients and families. Can nurses reduce hospital readmissions? Evidence has shown that if nurses are working in an inadequately staffed environment, the delivery of the care processes that can reduce rehospitalization may be hampered.14-17 Recently, McHugh and Ma examined the relationship between hospital nursing and 30-day hospital readmissions among Medicare patients with heart failure, acute myocardial infarction, and pneumonia.16 The researchers evaluated nurse staffing levels, nurse education, and nurses’ own assessment of their work environment, including such factors as the quality of nurse–physician relationships, nurse manager leadership, and nurses’ participation in organizational decision making. They analyzed patient discharge data from 412 hospitals and survey results from more than 20,000 nurses in California, New Jersey, and Pennsylvania, as well as data from the American Hospital Association Annual Survey. The study demonstrated that the probability of readmission increased with each patient added to the average nurse’s workload: by 9% among those with acute myocardial infarction, 7% among those with heart failure, and 6% among those with pneumonia. Compared with hospitals rated by nurses as having a poor working environment, hospitals with a good working environment had readmissions that were 10% lower among patients with pneumonia, 7% lower among patients with heart failure, and 6% lower among those with myocardial infarction. The authors found that nurses’ education level significantly affected readmissions for pneumonia but not for the other two diagnoses, noting that a “broader set of patient types should be considered to address the question of why having more nurses with BSNs affects readmissions for some patients and not others.” In summary, preventing or reducing readmissions requires efforts in several areas: not only evidencebased interventions but also a focus on system factors such as nurse staffing levels, work environment, and educational preparation. Regardless of their title or job description, all nurses play pivotal roles in reducing and preventing readmissions at a variety of points along the continuum of care, at the bedside, in discharge planning, and in postdischarge care management. Hospital readmissions are the result of many factors; therefore, many interventions across the continuum of care may be used to reduce them. In our efforts to reduce or prevent readmissions and improve patient care, we should focus on effective communication, coordination, and collaboration with patients, family members, and other care providers. Interdisciplinary teams are key in preventing readmissions, and nursing can lead the way. ▼ [email protected]
Jo Ann Brooks is system vice president, quality and safety, at Indiana University Health in Indianapolis. Contact author: [email protected]. The author has disclosed no potential conflicts of interest, financial or otherwise.
REFERENCES 1. Jencks SF, et al. Rehospitalizations among patients in the Medicare fee-for-service program. N Engl J Med 2009;360(14): 1418-28. 2. Medicare Payment Advisory Commission (MedPAC). Report to the Congress: promoting greater efficiency in Medicare. Washington, DC; 2007 Jun. http://medpac.gov/documents/reports/ Jun07_EntireReport.pdf. 3. Hines AL, et al. Conditions with the largest number of adult hospital readmissions by payer, 2011. Rockville, MD: Agency for Healthcare Research and Quality; 2014 Apr. HCUP statistical brief #172; http://www.hcup-us.ahrq.gov/reports/ statbriefs/sb172-Conditions-Readmissions-Payer.jsp. 4. Stone J, Hoffman GJ. Medicare hospital readmissions: issues, policy options and PPACA. Washington, DC: Congressional Research Service; 2010 Sep 21. CRS report for Congress R40972. 5. Foster RS. Estimated financial effects of the “Patient Protection and Affordable Care Act,” as amended Apr 22, 2010. http:// www.cms.gov/Research-Statistics-Data-and-Systems/Research/ ActuarialStudies/downloads/PPACA_2010-04-22.pdf. 6. Centers for Medicare and Medicaid Services. 42 CFR Parts 405, 412, 413, et al., Medicare program; hospital inpatient prospective payment systems for acute care hospitals and the long-term care hospital prospective payment system and fiscal year 2015 rates; etc.; final rule. Washington, DC: Federal Register 2014 49853-50536. 7. Centers for Medicare and Medicaid Services. FY2013 IPPS final rule: Hospital Readmissions Reduction Program supplemental data file. Baltimore, MD 2012. 8. Rau J. Medicare to penalize 2,217 hospitals for excess readmissions. KHN, Kaiser Health News 2012 Aug 13. http:// www.kaiserhealthnews.org/stories/2012/august/13/medicarehospitals-readmissions-penalties.aspx. 9. Rau J. Medicare revises readmissions penalties—again. KHN, Kaiser Health News 2013 May 14. http://www. kaiserhealthnews.org/stories/2013/march/14/revised- readmissions-statistics-hospitals-medicare.aspx. 10. Rau J. Armed with bigger fines, Medicare to punish 2,225 hospitals for excess readmissions. KHN, Kaiser Health News 2013 Aug 2. http://www.kaiserhealthnews.org/stories/2013/ august/02/readmission-penalties-medicare-hospitals-year-two. aspx. 11. U.S. Department of Health and Human Services. New HHS data shows major strides made in patient safety, leading to improved care and savings. Washington, DC; 2014 May 7 http://innovation.cms.gov/Files/reports/patient-safety-results.pdf. 12. Hansen LO, et al. Interventions to reduce 30-day rehospitalization: a systematic review. Ann Intern Med 2011;155(8):520-8. 13. Romagnoli KM, et al. Home-care nurses’ perceptions of unmet information needs and communication difficulties of older patients in the immediate post-hospital discharge period. BMJ Qual Saf 2013;22(4):324-32. 14. Kalisch BJ, et al. Missed nursing care: errors of omission. Nurs Outlook 2009;57(1):3-9. 15. McHugh MD, et al. Hospitals with higher nurse staffing had lower odds of readmissions penalties than hospitals with lower staffing. Health Aff (Millwood) 2013;32(10):1740-7. 16. McHugh MD, Ma C. Hospital nursing and 30-day readmissions among Medicare patients with heart failure, acute myocardial infarction, and pneumonia. Med Care 2013;51(1):52-9. 17. Weiss ME, et al. Quality and cost analysis of nurse staffing, discharge preparation, and postdischarge utilization. Health Serv Res 2011;46(5):1473-94.
AJN ▼ January 2015
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Vol. 115, No. 1
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